System Retrospect Clinical Documentation Specialist I Remote
Altamonte Springs, Florida
Employer: AdventHealth
Industry: Health Information Management
Salary: Competitive
Job type: Full-Time
AdventHealth Corporate
All the benefits and perks you need for you and your family:
• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Shift : Full-time; Monday - Friday
Job Location : Remote
The role you'll contribute:
Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value that you bring to the team:
• Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of
• love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and
• every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
• Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review to ensure the integrity of documentation compliance.
• Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars
• Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
Qualifications
The expertise and experiences you'll need to succeed :
• Associate and 5+ years experience
• 5 years acute care
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3 years of Clinical Documentation Specialist experience
• Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation
• CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
Preferred Qualifications :
• Associate and 5+ years experience
• 5 years acute care
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3 years of Clinical Documentation Specialist experience
• Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation
• CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
All the benefits and perks you need for you and your family:
• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Shift : Full-time; Monday - Friday
Job Location : Remote
The role you'll contribute:
Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value that you bring to the team:
• Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of
• love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and
• every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
• Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review to ensure the integrity of documentation compliance.
• Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars
• Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
Qualifications
The expertise and experiences you'll need to succeed :
• Associate and 5+ years experience
• 5 years acute care
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3 years of Clinical Documentation Specialist experience
• Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation
• CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
Preferred Qualifications :
• Associate and 5+ years experience
• 5 years acute care
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• 3 years of Clinical Documentation Specialist experience
• Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation
• CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification
Created: 2024-08-27
Reference: 24003171
Country: United States
State: Florida
City: Altamonte Springs
About AdventHealth
Founded in: 1973
Number of Employees: 80000
Website: https://www.adventhealth.com/
Career site: https://jobs.adventhealth.com/
Wikipedia: https://en.wikipedia.org/wiki/AdventHealth
Instagram: https://www.instagram.com/adventhealth/
Facebook: https://www.facebook.com/AdventHealth/
Similar jobs:
-
Teleradiology - 1st or 2nd shift - Flexible Part Time Fully Remote Opportunities
Envision Healthcare in Fort Lauderdale, Florida💸 $177400.00 per year -
Sales Representative (Remote)
J. J. Keller & Associates, Inc in Tampa, Florida💸 $53000 - $70000. per year -
Remote Regulatory Analyst
Insight Global in Boca Raton, Florida -
NP Licensed in FL - Telephonic After Hours - Per Diem - Remote
UnitedHealth Group in Tampa, Florida💸 $33.75 - $66.25 per hour -
QA Software Engineer - (Fully Remote in Select Locations)
Webstaurant Store, Inc. in Tampa, Florida -
Remote Overnight General Radiologist - Radiology Associates of Florida
radiology partners in Remote, Florida -
Marketing Support Supervisor - Remote
Hilton Grand Vacations in Orlando, Florida -
Project Coordinator, Cognos - Remote
Hilton Grand Vacations in Orlando, Florida -
Principal .NET Developer - Remote - USA
FullStack Labs in Tallhasse, Florida -
100% Remote 1st Shift 7 on / 7 off Diagnostic Radiologist
Envision Healthcare in Largo, Florida -
Sales Agent, Holland America Line - Remote US
Carnival Corporation in Miami, Florida -
AI/ML Solutions Architect - Remote - USA
FullStack Labs in Miami, Florida -
Remote- Licensed health insurance agent
RemX in Orlando, Florida💸 $21 per hour -
Case Manager RN - Remote in FL
UnitedHealth Group in Orlando, Florida -
Identity Management Engineer III (Remote)
Insight Global in Jacksonville, Florida -
Commercial Insurance, Sr. Account Executive (Hybrid Boston, MA or ET remote
National Financial Partners in Tallahassee, Florida -
Senior Electrical Engineer - 100% Remote
System One Holdings, LLC in Temple Terrace, Florida -
Deputy Program Manager (Work from home/remote opportunity)
Nana Regional Corporation in Orlando, Florida💸 $110000 - $125000 per year -
Senior Copywriter - Remote
Hilton Grand Vacations in Orlando, Florida -
Spring 2025 Internship - Course Scheduling (Remote)
AEG in Orlando, Florida